Pharmacy Technician

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Clinical Services-Pharmacy Full Time Clerical Wheeling, WV, US

The Pharmacy Technician is responsible for answering member, pharmacy, and provider questions as well as researching and resolving problems, to help members understand and optimize the use of their pharmacy benefit. Pharmacy Technicians also work with pharmacists to help review drug coverage requests from members, physicians, and pharmacies to determine medication coverage based on benefit plan design, client specifics, clinical notes, and clinical criteria according to the utilization management system(s).

Required:

• HighSchool diplomaorequivalent.
• Oneyearexperienceina retail,hospital,managedcare,orothersimilarpharmacysetting.
• Minimumtyping speed of35 words per minute
• Demonstrateworkingknowledgeofdirectclaimsprocessing,pharmacycomputersystems, spreadsheet applications ("i.e., Microsoft Excel"), phone system and other office/computer equipment as required.
• Knowledgeofpharmaceuticalgeneric andtradenames.
• Abilitytocomprehendandfollowestablishedofficeroutines,policies,andprocedures.
• Effectiveoraland writtencommunicationskills,includinggrammarandspelling.
• Strongorganizationalskills,timemanagementandmulti-taskingabilities.
• Detailorientedwithadvancedanalyticalandproblem-solving skills.
• Abilitytoworkeffectivelyaspartofateamandindependently.
• Follow all plan policies and procedures.
• Degreeinhealth-related field.
• Experience performing medication authorizations in pharmacy or managed care environment.

Responsibilities:

• Completes medication coverage requests through prior authorization criteria and escalates requeststoClinicalPharmacistsor Medical Directorswhenrequestsrequireclinicalrevieworisnotapprovable through the automated system.
• Contactsproviderstoobtain allnecessaryinformationforcoverage requests prior to referring cases to Clinical Pharmacists or Medical Directors.
• Attaches relevant policy(ies) for the medication requests to the case documents prior to referring cases to Clinical Pharmacists or Medical Directors.
• Identifies and documents the relevant policy information prior to referring cases to a Clinical Pharmacist or Medical Director for review.
• Resolvesanddocumentscoveragerequestoutcomesinpharmacybenefitmanager'ssystemand communicates decision to physician's office and/or members through verbal and/or written notification in accordance with company policies.
• Researches, resolves, and documents physician or member inquiries and grievances and documentsoutcomesinthepharmacybenefitmanager'ssystem,medicalreviewsystemor customer service tool in an accurate and timely manner.
• Providesverbalverificationofmember'splaneligibilityandapplicablepharmacybenefits.
• Utilizespharmacybenefitmanagerandmedicalreviewsystemtoupdate,modifyandextract member information.
• Detailsmembersandprovidersonpharmacybenefitinquiriessuchasformulariesand pharmacy networks.
• Assistspharmaciesinprocessingprescriptionclaims;reviewandtroubleshootclaimsfor accuracy and adherence to contract guidelines.
• Consultswithclinicalpharmacistsforguidanceandassistifnecessary.
• Gathers clinical documentation necessary for the performance ofmedicationreconciliationandyearlymedication reviews and refers documentation to a Care Management Pharmacist for review.
• Identifies and documents peer-to-peer requests and refers cases to a Clinical Pharmacist or Medical Director for review.
• Interactswithstaff,customerserviceandsupervisorstoensurebestpractices.
• Followspolicyandprocedurespertainingtoalllinesofbusiness.
• Ensuresturnaroundtimes meetrequirementswithcompany,state,andfederalregulations.
• Meets internal key performance indicators as defined in The Health Plan’s Policies and Procedures.
• ExplainsAppealandGrievanceprocesstomembersandproviders.
• Identifies, documents, and sends appeal requests to the Appeals and Grievances Department per Appeal and Grievance Department Policies and Procedures.
• AssistsAppealsCoordinator,ClinicalPharmacistandCompliancewithpharmacybenefit grievances as needed.
• Handles calls and correspondence after hours (when scheduled) regarding pharmacy issues from providers and members.
• Pharmacy Technicians are responsible for reporting any changes in licensure status (e.g., application declined/denied; license revoked/suspended or lapsed; notification of an investigation by licensing board; becoming subject to disciplinary action by a licensing board) to their direct supervisor throughout their term of employment.

Equal Opportunity Employer

The Health Plan is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. The Health Plan strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. The Health Plan employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.